Transfusion Medicine in Practice

MB Desmond, MB Duguid, MD Goodnough

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781000144475
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Transfusion Medicine in Practice focuses on the clinical applications of transfusion, discussing the different settings in which transfusion is carried out, including surgery, transplant, trauma, intensive care, and paediatric neonatal and obstetric cases. The text also includes a full discussion of transfusion products and how to use them, pharmacologic products as an alternative to blood, and transfusion service management. This practical text on the clinical practice of transfusion will be an invaluable resource for all those involved in the use of blood and blood products.

1 Hospital transfusion practice

Frank E Boulton

INTRODUCTION

There is no doubt that blood transfusion has saved lives. Unfortunately, some recipients have died from transfusion – although not always from administrative or technical ‘errors’. Some early recipients were victims of trauma (including obstetric) or had required major surgery, while others had profound ‘pernicious’ anaemia. A few were babies with haemorrhagic disease.

TRANSFUSION BEFORE 1940

Clinically based transfusion practice, conceived in the 1820s by James Blundell in London, gestated for nearly nine decades. Several Americans, including two Union soldiers in the Civil War, received human blood in the 1850s and 1860s (others got animal blood), with singular lack of success and occasional deaths through incompatibility.^1,2 Braxton Hicks – Blundell’s successor – used rather strong solutions of ‘phosphate of soda’ to prevent troublesome clotting of blood collected for transfusion. This worked, but few patients survived – although some rallied temporarily with the rather small volumes of ‘phosphated blood’ given. Brakenridge of Edinburgh was more successful with 5% phosphate (one volume to two or three volumes of blood) used within hours of collection for five patients diagnosed with pernicious anaemia.³ Incompatibility probably killed one. The same anticoagulant was used for a haemophiliac in 1910;⁴ this was the last recorded use of ‘phosphated blood’ being used.

Although defribrinated blood was used by some surgeons, adverse events were frequent and most surgeons at this stage favoured a ‘direct’ and rapid approach to avoid clotting. In 1905, Alexis Carrel successfully transfused blood from a New York surgeon to his newborn daughter who had haemorrhagic disease⁵ by surgically anastomosing donor artery to patient vein. Crile simply used a short metal tube over which the cut ends of the dissected-out vessels were cuffed to join donor to recipient. Elsberg’s similar device was used for Duke’s thrombocytopenic patient, from whom platelet function and the value of the bleeding time was first demonstrated. A major problem was the inability to measure the amount transfused – indeed, Duke’s donor probably gave more than a litre.⁶ An ingenious method for transfusing known volumes of unmodified blood was devised by Unger, who connected lines to recipient and donor via a four-way stopcock and a saline syringe.⁷ These direct methods (not to be confused with the later ‘directed’ methods of donor selection) had the major disadvantage of direct contact between donor and patient, and the surgery meant that donors could only be used once.

Incompatibility was still problematic. Although Landsteiner wrote ‘it might be mentioned that the reported observations [of his newly discovered blood groups] may assist in the explanation of various consequences of therapeutic blood transfusions’,⁸ no action was taken until Ottenburg introduced pre-transfusion compatibility testing.⁹ Even then, many surgeons would not wait – their patients were often in extremis. In his textbook (the first definitively on transfusion), Crile only faintly recognized the compatibility problem as ‘occasional hemolysis’ that occurred unpredictably.¹⁰ Landsteiner thought that blood group status was determined by serum agglutinins (antibodies); this was corrected when von Dungern and Hirschfeld demonstrated the Mendelian nature of ABO inheritance.¹¹

Phosphate failed to catch on, but sodium citrate – used for anticoagulating transfused cattle blood in 1911¹² – was first used for humans in Belgium in 1914. Appropriate doses were described by Lewisohn.¹³ A better citrate/glucose mix was devised for the Front in 1917.¹⁴ More suitable formulations resulted in Loutit and Mollison’s ‘ACD’.¹⁵ A few years later, Gibson¹⁶ added small amounts of phosphate in order to enhance the provision of nucleoside phosphate during storage.

Some transfusions were conducted in the interwar years – usually for surgical or obstetric problems, pernicious anaemia, or a few haemophiliacs. In the USA, many donors from the start were ‘professional’ (i.e. paid). The first ‘Blood Bank’ at Cook County Hospital, Chicago, in 1936 required the families of each patient to ‘deposit’ units of blood in exchange for each unit transfused.¹⁷ Following the Spanish Civil War, the onset of the Second World War galvanized a ‘regional’ system for blood collection from unpaid donors in Britain, which developed into the post-war National Blood Transfusion Services. Military influences were largely behind the drive to fractionate pooled plasma to produce albumin solutions as an alternative to freeze-dried plasma. Addition of mercury to preserve albumin solutions in tropical climes introduced a step that incidentally inactivated microorganisms.¹⁸ This improved when caprylate and heat pasteurization were introduced in the early 1950s. The transmission of hepatitis by blood was increasingly recognized during the Second World War.

DEVELOPMENTS AFTER 1945

Military influences continued during the Korean and Vietnamese wars, when frozen preservation was developed. Although not needed for routine transfusion, freezing proved essential for storing rare blood or stem cells. The invention of the plastic blood pack enabled ‘blood component therapy’ to develop.¹⁹ This was enhanced by ‘optimal additives’, which also improved red cell storage as well as increasing plasma yield for fractionation and easing cryoprecipitation for treating haemophiliacs.^20,21 This helped to meet the rapidly increasing demand for clotting factors, which, however, could only be fully met by using commercially donated apheresis plasma. Early apheresis systems operated with separate packs – at considerable risk to donors, who might, in a busy donor ‘clinic’, get someone else’s red cells returned. Machine-operated systems of ever-increasing efficiency were developed,²² which also enhanced ways of harvesting platelets and haematopoietic progenitor cells, and also of emergency treatment of hyperviscosity syndrome in people with acutely presenting leukaemia or Waldenström’s macroglobulinaemia.

Although tests for syphilis and (in some places) for malaria in donations were introduced very early, cytomegalovirus (CMV) was not recognized until 1965.²³ With the discovery of the ‘Dane’ particle,^24,25 and its association with ‘serum hepatitis’ (hepatitis B), a new era opened. Within 25 years many more viruses were recognized as transmissible by transfusion; human T-cell leukaemia/lymphoma viruses I and II (human T-lymphotropic viruses, HTLV-I and -II), human immunodeficiency virus (HIV), hepatitis A and C viruses (HAV and HCV), parvovirus, and other herpesviruses, as well as several viruses of uncertain pathogenicity such as ‘TTV’ and ‘HGV’. But it was the onset of HIV/AIDS in the early 1980s which had the most profound impact on transfusion services in the developed world.²⁶ The most recent development concerning disease transmission – prions – remains very uncertain, but has nevertheless had a profound impact in cost terms to the UK transfusion services through leading to ‘universal leukodepletion’ (see below).

The last three decades have witnessed astonishing advances. In the early days, cardiac surgery not only required a large amount of blood cover but also was instrumental in revealing transfusion-transmitted CMV infection.²³ Organ transplantation and neonatal intensive care has depended to a large degree on advances in transfusion therapy, as have the developing oncological services, whose patients experienced profound marrow suppression. Communities with significant populations from the Mediterranean littoral, Asia, and sub-Saharan Africa, in whom thalassaemia and haemoglobinopathies are common, also created new demands on the supply of red cells, while people with haemophilia or immunodeficiencies increased the demand for plasma derivatives. A recent pilot study,²⁷ combining data from a small mix of specialist and general English hospitals indicated an approximately equal usage of blood for medical and surgical patients; of the medical patient use nearly half was for malignancy and 13% for GI bleeding; while of the surgical causes nearly 30% was orthopaedic (including emergencies), a quarter were for cardiac and 9% for arterial surgery. Seventy percent of recipients were older than 50 years and 10% were younger than 20 years. Approximately 17% of blood recipients died within 6 months (of their primary disease). Comparable studies have been made in France and Denmark.^28,29 Surgical use offers an important target for reduction, although blood use for patients in all these categories needs to be scrutinized.

In 1999, in response to the discovery in 1996 that humans could be infected by the BSE prion – giving rise to a new form of Creutzfeld–Jakob disease (vCJD) – the UK Transfusion Services implemented a scheme of ‘universal leukodepletion’. This was in response to independent advice³⁰ that indicated (on the basis that vCJD infectivity was associated with white cells) that leukodepletion was in the public interest. It is still too early to ascertain whether this has had any beneficial effect, but some observers in the UK hope that some ‘incidental benefits’ – in the shape of fewer non-haemolytic febrile transfusion reactions and reduced alloimmunization – will prove significant; but views from outside are less optim...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• 1. Hospital transfusion practice Frank E Boulton
• 2. Transfusion products Susan Knowles
• 3. Blood transfusion in patients requiring long-term support Aleksandar Mijovic
• 4. Transfusion support in transplantation Darrell J Triulzi, Ileana López-Plaza
• 5. Blood and blood component use in cardiac surgery or ‘why do cardiac surgical patients bleed?’ Robert R Jeffrey, Michael J Desmond
• 6. Surgical transfusion: Non-cardiac Lawrence Tim Goodnough, Terri G Monk
• 7. Major obstetric haemorrhage Simon Bricker
• 8. Paediatric and neonatal transfusions Paula HB Bolton-Maggs
• 9. Transfusion practice in resuscitation and critical illness Gary Masterson
• 10. Pharmacologic alternatives to blood Lawrence Tim Goodnough
• 11. Congenital and acquired disorders of coagulation Jeanne M Lusher, Roshni Kulkarni
• 12. Therapeutic apheresis Mark E Brecher
• 13. Transfusion service management James P AuBuchon, Dafydd W Thomas
• Index